Reddish-purple mottled area on my shoulder - DCS?

[Chris Johnson]

After my last 2 dives, my wife noticed that I had a reddish-purple mottled area on my shoulder. These dives were both about 35 min @ 65ft, with a 3 min safety stop each and a 1hr surface interval. I was breathing EAN32 Nitrox. I was well within the no-deco limits. This is an excerpt from a post by John Reinertson, in which he posted some info from Dr Ernest Campbell's web site. (scuba-doc.com)

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Patchy erythema (Cutis Marmorata)
Patchy, reddish-purple mottled areas can occur, especially around the shoulders and trunk. These are intensely pruritic and are due to a local vascular reaction from bubbles in the tissues below the dermis. This has a more serious connotation and is thought of as a systemic manifestation of decompression sickness.
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'Intensely Pruritic' means they itch a lot right? Mine didn't itch at all. At the time I assumed it was from all the heavy gear I was lugging around - 120 cu ft steel tank and gear bag carried by shoulder strap.

Do I need to worry? This has already helped me decide to get in better shape and go to EAN36 (unless I dive deeper).

Thanks for the help!

 

[DocVikingo]

Hi Chris,

Cutis marmorata related to DCS often is intensely itchy, especially in the initial stages of development, but I do not believe this is true for 100% of cases. Still, the fact that your area did not itch at all seems to argue against a dx of DCS.

In addition, I do not believe one would expect to see cutis marmorata as the sole sign of DCS. Its presence would likely be accompanied by other signs or symptoms of the disorder.

While this does not mean one cannot have DCS, dive profiles such as reported would be considered within normal limits & not courting risk.

This is educational only and does not constitute or imply a doctor-patient relationship. It is not medical advice to you or any other individual, and should not be construed as such. If you have signs & symptoms of DCS, contact your physician.

Best regards.

DocVikingo

 

[octodiver]

Hi Chris,

I'm the "skin bends" lady with a little something to add...
Did you have any pain associated with that area of discoloration? Did you experience any
extreme fatigue (as in more than you would normally associate with that level of activity)?
I know 2 people who had skin bends without itching.

While your profiles weren't necessarily "provocative", there are the questions of your ascent
rates, in general, and your ascent rate from your safety stop (I've seen lot's of folks "bolt"
to the surface at the end of their SS). Remember, the closer you are to the surface, the slower
you need to ascend...

And lastly, don't forget about the whole "predisposing factor" issue. It doesn't matter what
the "tables" say the limits are - your body has it's own limits that may be affected by the presence
of a PFO, your age, fitness level, hydration level, etc...

I had undeserved skin bends episodes, and with the help of John Reinertson, decided to
be tested for a PFO. Unfortunately, I do have one and have been advised to stop diving.
I'm not saying that you need to run out and get tested, but undeserved skin bends do
point to PFO's. The first problem is finding a doctor who can correctly dx that kind of DCS.
(Mine suggested that I had urinated in my wet suit too many times and/or was having a reaction
to a new skin lotion!!)

Be safe, and pay attention to any similar signs after any dives - close to the limits or not!
And call DAN if you have any concerns...

Octodiver

 

[Dr Deco]

Dear Octodiver:

The question of a PFO and DCS is continuing. It is a big question here at NASA with regard to test subjects. There are some that are of the opinion that it is a critical question and others who do not feel that the evidence indicates cause for concern.

There are several aspects to this question. As far as recreational scuba divers are concerned, it does not seem to be a major problem. This is probably because recreational divers do not produce that many decompression gas bubbles. Without the decompression bubbles (generated in muscle and fat tissue), there is nothing to pass into the arterial circulation and ultimately be carried to the brain.

The second aspect is considerably more controversial. (This means, that I am the only one who noted it when it regards diving.) Tests for a PFO are always made with the individual lying down. They are recumbent with the saline contrast is inject. A report recently published regarding bubbles and cranial surgery indicates that when the person is in the erect posture, the number of gas bubbles passing through the PFO is quite a bit less than when the individual is recumbent. The results of this seem to indicate one reason why many people are “positive” for a PFO, and yet they do not demonstrate arterialization during decompression even when they have a considerable number of decompression bubbles in the right heart. (This has been extensively studied in hypobaric [altitude] studies.)

You have apparently demonstrated skin mottleing and a PFO. Some medical researchers believe that there is a causal link. If one is very careful about those activities they cause gas bubble formation, the risk of DCS should be very low. Those activities are vigorous physical activity in the off gassing portion of the dive (especially when entering the boat and on the surface). "Table limits" do not have anything to do with this.

I hope that this helps.
____________
Dr Deco

 

[scubadoc]

Hello Chris:

There is nothing certain on this Earth except death and taxes - and I'm not worried much about death. The same can be said about skin bends; 'cutis marmorata' means near-death, severe decompression sickness to some people and to others it means a mild accident. Not all skin bends is cutis marmorata.

More recently skin bends has been associated with bubbles being arterialized across an inner wall of the heart (patent foramen ovale). As previously stated above, it usually is 'itchy' but can also be described as 'heat'.

One thing for certain, any symptoms after a dive that are unusual should not be ascribed to something else, such as strap pressure or some other extraneous reason. It is too easy to slough off a decompression problem that should be treated and diagnosed.

This may not be DCS at all but- the best advice here would be to assume the worst case scenario, get yourself to a dive oriented physician and have an appropriate echocardiogram to rule out a PFO. Otherwise, you are setting yourself up for possible future accidents; in addition, you won't feel easy about yourself with your diving unless you get this done.

 

[octodiver]

Dear Dr. Deco,

Thanks so much - it certainly does help! The more I learn, the more questions I have!

1) I'm confused by your statement that "table limits" don't have anything to do with "this".
Do you mean that vigorous physical activity post dive can allow for the shunting of bubbles
(where there's a PFO present) after almost ANY "safe" profile? Is your position that
it's an individual's tendency toward "bubbling" that causes so called "undeserved" hits,
rather than the presence of a PFO or other "predisposing factors" such as age, weight,
physical fitness level? (Or are these the characteristics that create one's tendency?)

There are two of us (instructors w/PFO & skin "bends") who've been "symptom free" post
diving for approx. 20 months and 800 dives (95% from shore). We rarely go beyond 35 feet
and when we do we dive Nitrox 36 - 38. Last skin episode was when we did a shore dive to
47 feet (average 30 feet) for 73 minutes on air (this brought us close to the PADI table limit).
Now that's a Nitrox dive.

2) Should the presence of a med/large PFO be a contraindication for diving since even the straining from
climbing up a ladder or exiting from a beach dive seems to be enough to raise the pressure
in the right atrium?

3) What safe ascent rate would you recommend from 15 - 20 ft. for those with PFO's?


Should we move this discussion to a new thread?

 

[John Reinertson]

Hi Octo Diver;

As Dr. Deco has alluded, if there are no bubbles, there are no troubles. The percent of people that bubble increases the closer one gets to No Deco Limits, and goes up a lot past the limits. The PFO just allows the bubbles a route to get where you don't want them. (Just as going beyond the limits doesn't guarantee DCS, staying short of them doesn't guarantee freedom from DCS.)

Since people with patent Foramen Ovale do not bubble or get DCS if they don't change pressure (stay at sea level), There has to be a place between the ND limits and not diving at all where the risk for people with PFO's fades to near zero.

Unfortunately, medicine doesn't have a clear answer as to where that level is. Dr Deco is the expert here, so I'll bow to his expertise if he knows a level considered a safe haven.

Lacking that, the best current medical knowledge that I'm aware of is that the risk goes down significantly with less aggressive profiles, caution on exertion after diving, and slower ascents.

I wish we had more definite answrs and data than that, but that's true of a lot of medical knowledge.

Dive safe and Bubble Free,
John